IntroductionThis packet includes human resources (HR) templates that dairy farms can tailor for use on their operation. The templates are provided for informational purposes only. Farms are responsible for determining whether the templates meet compliance requirements of their applicable local, state, or federal laws and regulations. National Milk Producers Federation and the National Dairy FARM Program are not responsible for the content of these templates, and under no circumstances shall we have any liability to you for any loss or damage of any kind as a result of the use of the templates or reliance on any information provided in the templates. Once downloaded by an organization or an individual, these templates and their content become the sole property and responsibility of the organization or individual.

InstructionsThe following templates should be tailored by the individual farms to best suit the operation’s needs. Some fields in the templates can be filled in directly through the Word document.

Fill in the Company / Dairy Name here, then press Ctrl+A, then F9. This will automatically update the company name throughout the templates. Company Name: Click or tap: Company Name

Additional instructions and notes are provided for the following templates.

Job Application – LongIt is important to note that employers cannot discriminate against an individual for a temporary work authorization that does not require employer sponsorship. However, in general, employers are permitted to ask about whether an individual currently or will need employer-sponsored work authorization. See the following resource: https://www.laboremploymentperspectives.com/2012/08/30/employment-authorization-ask-but-ask-carefully-part-2/

Additionally, many of the top dairy-producing states are ‘ban the box’ states where you cannot ask an applicant a yes/no question about criminal history on a job application. Farms should check with a licensed attorney in their state before adding such a question to their job application form.

If conducting a background check, a background check authorization form must be included as a separate signed document. State laws vary in the type of disclosures that you must give individuals when conducting a background check. Consult with a licensed attorney and/or ask the company that you use for background checks to give you a form and disclosure documents specific to your state(s).

Interview Questionnaire Form

Human Resources Templates

The form can be used to take notes during an interview and rate an applicant based on their responses. Questions should be selected ahead of time and should be the same for each interviewee.

Employee Training LogEmployees and supervisors can track all of the training an employee has received using a training log. The training log can be combined with the FARM Animal Care Dairy Cattle Care Training Log or kept separately. The top portion should be signed once all new hire trainings are complete.

Compensation Change FormState law may have specific requirements on what information must be given to an employee when there is a change in pay and when they must be informed of the change. Check state law before using the form as a notice to an employee.

Employee Safety Incident Reporting Form This form can be used to track injuries, even minor ones, as well as near misses. This form DOES NOT replace First Report of Injury forms required by workers’ compensation, or any other legally required injury or illness reporting or recordkeeping. Documenting injuries and near misses helps identify trends; however, the documents may be discoverable during litigation. Work with a licensed attorney or safety consultant to understand how best to approach documentation for your operation.

Emergency PosterAll workers should know exactly what to do and who to call in case of an emergency. Consider displaying a poster, like the example provided, to remind everyone what to do. Posting the names and telephone numbers of emergency contacts in a prominent place in farm-provided housing in employees’ native languages speeds up communications in an emergency.

Repair Journal SystemThe following can be printed or placed in a binder accessible to all workers. Workers can fill out the first three columns to request housing repairs or information. A manager who checks the binder will fill out the last three columns.

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This resource is not a legal document and is intended for educational purposes only. Dairy farmers are individually responsible for determining and complying with all requirements of local, state and federal

laws and regulations.

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Job Description WorksheetThis worksheet can be filled in to help dairy owners and managers develop a job description.

Dairy Name: Click or tap: Company NameClick or tap: Company Name

Address: _____________________________________________________________

Name of Hiring Manager: ______________________

Phone Number: _________________________

E-mail Address: ________________________

Job Title: __________________________

Job Summary:The summary should be a short description of the job, about 3 or 4 sentences. It can include what the job is, where it is located, whether there are any special qualifications or physical requirements. The summary can be used in a public job posting.

Duties, Tasks, and Responsibilities:This section should list the duties and tasks the employee will perform. If the role involves several types of responsibilities, the dairy may wish to group them. For example, a Milker may have ‘Milking Responsibilities’ (prepare milking equipment, milk all cows in orderly fashion, etc.); ‘Milking Related Activities’ (maintain treatment records, assist in ordering supplies, etc.); and, ‘Other Responsibilities’ (other duties as assigned, maintenance of free-stalls, maintenance of vacuum pumps, etc.). Dairies may wish to specify the approximate % of time spent in each type of responsibility.

• _____________________________________________________________________

• _____________________________________________________________________

• _____________________________________________________________________

• _____________________________________________________________________

• _____________________________________________________________________

• _____________________________________________________________________

• _____________________________________________________________________

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• _____________________________________________________________________

Supervision:State what job/role this position reports to and what level of supervision the job will receive (e.g. regular, minimal, etc.).

Position reports to _____________________

Job receives (Minimal / Regular / Other) supervision.

Qualifications:Some jobs require past experience or educational qualifications. This section should describe those requirements. If applicable, qualifications can be divided into those that are ‘required’ and those that are ‘preferred’. Avoid statements that might be discriminatory on grounds of any protected class, like race, gender, age, or national origin.

Experience, type and years required (e.g. 3-5 years working with large animals):

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Education and Training (e.g. high school diploma or GED; food safety training):

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Certifications / License (e.g. driver’s license)

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Skills, Abilities, and Attributes (e.g. ability to read / write, ability to operate computer, attention to detail)

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Physical Requirements:List and describe any special physical requirements of the job. The following list can be used as a starting point; check any of the following are required on a day-to-day or infrequent basis.

Strength (Lifting, Carrying, Pulling, Pushing)

Kneeling Crawling

Standing Climbing ReachingWalking Stooping BalancingSitting Crouching Talking

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Hearing Seeing (near/far) Depth perceptionColor vision Field of vision

Work Environment / Conditions:Describe the environment for this position. Include information pertaining to temperature fluctuations or excesses, noise level, chemical irritants, dust or allergen exposure.

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Schedule:Describe the typical hours or shifts. Is the position part-time or full-time? Does it entail overnight shifts? What are the typical hours per week? Does the workload vary by season?

Compensation:It is optional to specify a starting wage, but it can benefit recruiting efforts. Dairies may consider listing a wage range, with a note that the exact compensation depends on experience. Owner and managers may also wish to list incentive or bonus programs.

Non-Wage Benefits: Highlight non-wage benefits that the dairy offers, like paid health insurance, paid vacation leave, or housing. The job description does not need to contain a full list of non-wage benefits. This section is to help with recruiting.

External Resources: Cornell University PRO-DAIRY Program, Job Description Development Worksheet,

https://prodairy.cals.cornell.edu/business-management/resources/ PennState Extension, Job Description Generator for the Dairy Industry,

https://extension.psu.edu/job-description-generator-for-the-dairy-industry PennState Extension, Job Descriptions: The Building Blocks of Organizations,

https://extension.psu.edu/job-descriptions-the-building-blocks-of-organizations Purdue Extension, Developing Effective Job Descriptions for Small Businesses and

Farms, https://www.extension.purdue.edu/extmedia/ec/ec-728.pdf University of Nebraska – Lincoln Extension, Examples of Job Descriptions for Major

Positions on Dairy Farms, http://extensionpublications.unl.edu/assets/pdf/g1585.pdf

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Job Application Form - ShortThank you for your interest in applying for a job at Click or tap: Company NameClick or tap: Company Name.Please complete the following application completely and truthfully.

Personal InformationFirst Name: Last Name:

Address: Date of Application:

Phone Number: Email Address:

Are you authorized to work lawfully in the United States? □ YES □ NO

Do you authorize this farm to contact your references? □ YES □ NO

Job Information

Position applying for (if known):Available start date:

Desired pay:

Qualifications

Education or Training:

Licenses / Certificates:Other:

References: Please provide three work-related references that can talk about your qualifications and employment history. Do not list family members.Name Phone Number Relationship

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

Name (please print) _____________________________________

Signature _____________________________________ Date:____________

All qualified applicants will receive consideration for employment without discrimination based on age, sex, national origin or any other protected classification.

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Job Application Form - LongThank you for your interest in applying for a job at Click or tap: Company NameClick or tap: Company Name. Please complete the following application completely and truthfully. You may also attach a resume if you desire. Any person found to have intentionally misrepresented or omitted any material fact in this application will automatically be disqualified from further consideration of employment.

Personal InformationFirst Name: Last Name:

Address: Date of Application:

Phone Number: Email Address:

Are you interested in: □ Part time □ Full Time □ Temporary □ Seasonal

Days and Hours AvailableMON TUE WED THUR FRI SAT SUNFrom From From From From From From

To To To To To To To

Are you authorized to work lawfully in the United States for Click or tap: Company NameClick ortap: Company Name? □ Yes / □ No

Will you now or in the future require Click or tap: Company NameClick or tap: Company Name to commence (“sponsor”) an immigration case in order to employ you (for example, H-1B or other employment-based immigration case)? This is sometimes called “sponsorship” for an employment-based visa status. □ Yes / □ No

Do you authorize Click or tap: Company NameClick or tap: Company Name to contact your references? □ Yes / □ No

If selected for employment, will you consent to a background check? □ Yes / □ No

Job InformationPosition applying for (if known):Available start date:

How did you learn about this position?

Desired pay:

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Desired hours:

Interests & ExperienceWhy are you interested in working on a dairy farm?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Do you belong to any organizations, clubs, advocacy groups?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Do you have a valid Driver’s License? □ Yes / □ NoDo you have a valid Commercial Driver’s License? □ Yes / □ No If yes, class:______________Are any of your Driver Licenses subject to any conditions? □ Yes / □ No

If yes, please explain: _____________________________________________________

Please circle each one of the following in which you have experience:

Milking Equipment Maintenance: Vacuum pumps / Refrigerant Levels / Pulsators /

Milk lines / Milk Hoses / Wash cycles / Hydraulics

Field Work: Hand Line Irrigator / Pivots / Wheel line

Milk Parlor: Milker (Herringbone / Parallel / Rotary) / Pusher

Herdsman/Maternity/ Hospital: Meat Withhold Periods / IV treatments / Artificial

Insemination / Heat Detection / Foot Health / Body Condition Scoring / Mastitis

Prevention / Mastitis Treatment

Programs: DHI plus / Dairy Comp / Dairy Quest

Vehicle Operation: Manual Transmission / Manure Truck / Side Dump Trailer / Belly

Dump Trailer Feed Truck / Front End Loader / Bobcat / Scraper Tractors / Swather / Hay

Rake/Merger / Hay Bailer

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General Maintenance: Machinist / Mechanic / Welder / Carpenter / Electrician / Plumber

List your qualifications for the job. Use the job description as a reference for what the position requires.Education or Training:

Licenses / Certificates:

Other:

Employment HistoryPlease list your last three jobs.

(1) Employer: ___________________ Dates Employed: _______________________

Address: ____________________________________________________________

Telephone Number: _________________

Job Title & Work Performed: _______________ Supervisor’s Name: _____________________

Reason for Leaving: _______________________________________________________

(2) Employer: ___________________ Dates Employed: _______________________

Address: ____________________________________________________________

Telephone Number: _________________

Job Title & Work Performed: _______________ Supervisor’s Name: _____________________

Reason for Leaving: _______________________________________________________

(3) Employer: ___________________ Dates Employed: _______________________

Address: ____________________________________________________________

Telephone Number: _________________

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Job Title & Work Performed: _______________ Supervisor’s Name: _____________________

Reason for Leaving: _______________________________________________________

ReferencesPlease provide three work-related references that can talk about your qualifications and employment history. Do not list family members.Name Phone Number Relationship

Additional CommentsPlease provide any additional information relevant to your application.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

Name (please print): ___________________________

Signature ____________________ Date __________________

All qualified applicants will receive consideration for employment without discrimination based on age, sex, national origin or any other protected classification.

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Job Application Form Employer CommentsStaple this sheet to any job application you receive to keep track of next steps.

Application received on (date): _____________________________

Application reviewed by (name): ____________________________

Follow-up (check all that apply):□ Reviewed application and declined to interview.

□ Reviewed application and will call to schedule an interview

□ Scheduled an interview for: ___________________ (date)

___________________ (time)

□ Interviewed the applicant but decided not to offer them the position. Notified the

applicant of the decision on: ___________________ (date).

□ Offered the applicant the position on: __________________ (date). Asked them to

accept or reject the offer by _____________________ (date).

□ Candidate rejected the job offer.

□ Candidate accepted the job offer and will be starting on ______________________

(date)

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Interview Questionnaire Form

Name of applicant: Date:

Position interviewing for: Interview conducted by:

Question Response NotesE.g. Tell me about your dairy experience.

Additional notes or feedback about the candidate:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Overall applicant rating. Circle one after the interview:5 – Excellent 4 – Above Average 3 – Average 2 – Below Average 1 – Poor

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Employee Emergency Contact Form

Name: _________________________________

Personal Contact Info:

Home Address _________________________________________________

City, State, ZIP __________________________________________________

Home Telephone # ____________________ Cell # ______________________

Emergency Contact Info:

(1) Name____________________________ Relationship________________

Home Address _________________________________________________

City, State, ZIP __________________________________________________

Home Telephone # ____________________ Cell # ______________________

Work Telephone # _____________________

(2) Name____________________________ Relationship________________

Home Address _________________________________________________

City, State, ZIP __________________________________________________

Home Telephone # ____________________ Cell # ______________________

Work Telephone # _____________________

I have voluntarily provided the above contact information and authorize my employer and its representatives to contact any of the above in the event of an emergency.

Employee Signature __________________________

Date __________________________________

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Progressive Disciplinary Action Form

Employee Name: _____________________________ Date: _________________ Position: _________________________

Reason for Disciplinary Action: (Check all that apply.)

___ Quality ___Productivity ___ Safety ____Conduct ___ Attendance

____ Insubordination ___ Housekeeping ___ Miscellaneous

You are receiving this disciplinary warning because of the following actions. (Describe in detail in behavioral terms.)

Unless this problem is corrected, further disciplinary action will be taken up to and including the termination of your employment. (Check the appropriate step in the progressive discipline policy.)

_____ Written Verbal Warning

_____ Written Warning

_____ 1-Day Suspension OR

_____ 3-Day Suspension OR

_____ 5-Day Suspension OR

_____ Employment Termination

Supervisor’s Signature: __________________________________ Date: _______________

I have received this disciplinary action and understand that unless this problem is corrected, further disciplinary action will be taken up to and including the termination of my employment.

Employee comments (if any):

Employee’s Signature: ___________________________________ Date: _______________

Human Resources Representative Signature: _________________ Date: _______________

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New Hire Checklist

Before Employment□Basic Information to Give New Hire Before They Start

□ When to arrive on the first day□ Who to ask for upon arrival□ What documents to bring on the first day (i.e. passport, driver’s license, or other

identification for I-9 verification)□ What to wear□ Where to park

□Inform other employees or family that a new employee will be starting on ____________ date.

□If applicable, ensure any materials and equipment are ready before the employee starts.

□Plan for safety and job training The new employee will need to be trained, both to do their job and on safety procedures. Before they start their first day, the dairy owner / manager should be sure to have a plan for who will train the employee and when.

First Day□ Introduce the Farm’s Mission, Vision, Culture and IdentityUpon the new hire’s arrival, give a warm welcome, an explanation of how the day will unfold, and take a few moments to explain the organization’s:

• culture (organization background)• values • vision and mission (what you believe, how you operate and an explanation of your goals)

□Review New Hire Paperwork• I-9 Employee Eligibility Verification• W-4 Federal Employee Withholding• State Tax Withholding Forms• Work Agreement and/or Job Description Form (Requirement varies by state)• Signed Deduction Authorizations (Requirement varies by type and state)• Dairy Cattle Care Ethics Agreement

□Review Company Policies and ProceduresGo over the dairy’s policies and procedures, using the employee handbook as a guide, if applicable. If the dairy requires the employee to sign an acknowledgment of policies or the handbook, be sure to give ample time for the employee to review the documents. Employees with low literacy may need to have the documents read out-loud. Dairy’s that often hire non-fluent English speakers should expect to translate written policies. Items that can be covered include:

• Work or shift hours• Overtime policy, if applicable• Leave: vacation, sick Attendance and absences• Breaks• Drug-free workplace

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• Discipline procedure• Performance reviews• Discrimination and harassment• Safety policies and procedures• Training procedures• Animal care

□Discuss Timesheets and Pay ScheduleIf employees will be expected to fill out a timesheet or similar form to record hours, the owner / manager or supervisor should explain the procedure on the first day. The employee should be told the procedure for payment and the payday. If applicable, provide enrollment forms for direct deposits.

□Review Benefits and Related FormsOn the first day, the owner / manager or supervisor should discuss non-wage benefits that the dairy may offer, like health insurance or retirement plans. Enrollment forms should be shared with the employee with instructions on how to complete them and where to return them.

□Review the Job ResponsibilitiesReview the responsibilities of the employee’s new job. The written job description is a helpful guide to outline key duties and expectations. Some dairies may wish to have a new employee sign the job description to confirm their understanding of the role.

□EquipmentGive the employee the required equipment, including keys, cell phoneComplete all paperwork Review the pay and payment schedule. Make sure the employee signs the appropriate income tax forms. Have the new hire complete an emergency contact form.

□Welcome and walking tour Conduct a walking tour of the dairy with the new employee. Point out important areas, like break areas, bulletin boards, and bathrooms. Show the employee the location where legally-required labor and safety posters are displayed. Introduce the new employee to staff – explain each person’s role and vice versa. Provide the new employee with an organizational chart, if available. Assigning a “buddy” to each new employee is helpful for answering simple questions that might come up in the first couple of months of employment.

□ Schedule or conduct safety and job training Some training may be conducted on the first day (especially safety training). Other training may happen over the course of the first few weeks.

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Employee Training Log

I confirm that I have received training in my all of my job responsibilities, health and safety procedures, animal care, and stockmanship.

Employee Name: _____________________________________________________

Farm Name: Click or tap: Company NameClick or tap: Company Name

Farm Owner/Manager: _________________________________________________

Description of training(s) received: ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Signature: __________________________________ Date: ___________

Description of training(s) received: ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Signature: __________________________________ Date: ___________

Description of training(s) received: ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Signature: __________________________________ Date: ___________

Description of training(s) received: ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Signature: __________________________________ Date: ___________

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Description of training(s) received: ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Signature: __________________________________ Date: ___________

Description of training(s) received: ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Signature: __________________________________ Date: ___________

Description of training(s) received: ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Signature: __________________________________ Date: ___________

Description of training(s) received: ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Signature: __________________________________ Date: ___________

Description of training(s) received: ___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Signature: __________________________________ Date: ___________

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Group Training Attendance Form

Course Name:_________________________________ Date: ___________________

Instructor(s): __________________________________

Length (hours): ___________________

Description of Content:

By signing this form, you are confirming your attendance at the training session(s) detailed above.

Employee Name Signature

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Performance Review FormEmployee Name: Supervisor Name:

Date of Review:

Supervisor AssessmentTo be completed by the supervisor prior to the performance review meeting.

How would you rate the employee’s performance in each of the following job areas? Check one and write in any relevant notes. Where possible, include quantitative measures of performance in the notes (for example, was tardy 0 times in the past year).

Job area Excellent Good Average Poor Notes

Job knowledge

Work quality

Technical skills

Consistency

Productivity

Attitude

Work Relations

Punctuality

Attendance

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Employee AssessmentTo be completed by the employee prior to the performance review meeting.

How would you rate your performance in each of the following job areas? Check one and write in any relevant notes. Where possible, include quantitative measures of performance in the notes (for example, was tardy 0 times in the past year).

Job area Excellent Good Average Poor Notes

Job knowledge

Work quality

Technical skills

Consistency

Productivity

Attitude

Work Relations

Punctuality

Attendance

Performance Review Meeting

Discuss areas where the employee is excelling and doing a good job. Record any notes.

___________________________________________________________________________

___________________________________________________________________________

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___________________________________________________________________________

Discuss opportunities for improvement. Record any notes.

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Discuss what resources the employee needs to help them improve, for example more training.

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Talk about the employee’s career goals – where do they want to be in the next year? In the next 5 years?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Set concrete goals for the next year.

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

By signing this form, you confirm that you participated in the performance review meeting. Signing this form does not necessarily mean that you agree with the performance evaluation.

Employee Signature ________________________ Date ________________

Supervisor Signature________________________ Date ________________

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Compensation Change FormEmployee Name: __________________ Position: _______________________

Salary Change

Effective Date: ___________________

Type of Change:□ Cost of Living / Annual Adjustment□ Merit Increase□ Promotion Increase□ Salary Decrease□ Other: _________________

Current Salary: $________________ per hour OR $_______________ per year

Proposed Salary Change: ________ % OR $______________ per hour / per year

New Proposed Salary: $__________ per hour OR $__________________ per year

Explanation for Change

Use the space below to provide a rationale for the above change.

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Signature Approvals

Supervisor Signature ________________________ Date ________________

HR Representative Signature__________________ Date ________________

Employee AcknowledgmentBy signing this form, you acknowledge that you received the above salary change information.

Employee Signature ________________________ Date ________________

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Break Relief Schedule Sheet Date Supervisor Name

Employee Name

1st Break___ Minutes

2nd Break ___ Minutes

Meal Period ___ Minutes

Time Scheduled Actual Time

Scheduled Actual Time Scheduled Actual

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Employee Safety Incident Reporting FormInstructions: Employees shall use this form to report all work-related injuries, illnesses, or “near miss” events (which could have caused an injury or illness) – no matter how minor. This helps us to identify and correct hazards before they cause serious injuries. This form shall be completed by employees as soon as possible and given to a supervisor for further action.

I am reporting a work-related: □ Injury □ Illness □ Near miss

Employee Name: Position:

Supervisor:

Date of injury/near miss: Time: □ A.M. □ P.M.Where, exactly, did it happen? What were you doing at the time of the incident/injury?

Describe clearly and in detail what happened/how you were injured (use the back of the page if needed):

Part(s) of body that was injured (be specific - such as left hand or right thumb). If a near miss, what part(s) of the body could have been hurt?

What could have been done to prevent this injury/near miss?

Describe any First Aid given at the scene of the injury:

Did you see a doctor about this injury/illness? □ Yes □ No

Who did you report the incident/injury to?

When did you report the incident/injury? (give date and time):

Name all witnesses (if any):

Employee signature: Date:

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Housing Orientation Checklist

Orientation Performed By: ____________________________________

Date of Orientation: ____________________________________

TOPIC TALKED ABOUT?

If Yes, ✓

ResponsibilitiesHouse RulesReporting Repair NeedsEmergency SituationsInspection Process and ScheduleKitchenBathroomsBedroomsWindows and DoorsWasher and DryerCommon AreasHeating and/or Air ConditionerWater SystemSmoke/Carbon Monoxide AlarmsWaste

Employee Name: ____________________________________

Employee Signature: ____________________________________

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Housing Inspection ChecklistCondition Cleanliness NotesWorking Damaged /

BrokenGood OK Bad

Living RoomFloor & Floor CoveringWalls & CeilingDoorsLighting FixturesWindows & ScreensWindow CoveringsSmoke AlarmCarbon Monoxide Alarm

KitchenFloor & Floor CoveringWalls & CeilingDoorsLighting FixturesWindows & ScreensWindow CoveringsCabinets and DrawersCountersStover/Burners, ControlsOven/Range HoodRefrigeratorDishwasherSink & PlumbingGarbage DisposalFire Extinguisher

BathroomsFloor & Floor CoveringWalls & CeilingDoorsLighting FixturesWindows & ScreensWindow CoveringsCounters & SurfacesSink & PlumbingHot Water

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Bathtub/ShowerToiletInside Drawers

BedroomsFloor & Floor CoveringWalls & CeilingDoorsLighting FixturesWindows & ScreensWindow CoveringsClosets, including DoorsSmoke AlarmBeds

OtherHeating SystemAir Conditioning SystemStairsHallwayLawn & GardenPatio, Terrace, Deck, etc.Parking AreaFront/Back PorchTrash Area

Additionally, each inspection should confirm that there are enough beds for all occupants. Beds should be at least 3 feet apart and 1 foot off the floor. Bunk beds should be 4 feet apart.

Housing Location: ____________________________________ Date: ________________

Inspected By: ____________________________________

Adapted from Cornell Agricultural Workforce Development.

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Emergency Contacts

Farm Name: ________________________________________________________________________

Housing Address: ___________________________________________________________________

Owner / Manager: Phone Number: __________________

FOR GENERAL EMERGENCIES, CALL 9-1-1

A First Aid Kit is Located: ___________________________________________________________

Daytime Urgent Maintenance: Phone Number: _________________

Nighttime Urgent Maintenance: Phone Number: __________________

Closest Medical Facility: Phone Number: __________________

Poison Control Phone Number:

Local Police Phone Number:

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Repair TicketThis form can be used by workers to request repairs or housing information.

Name: Date: Housing Location: __________________

Problem or Question: ______________________________________________________________________

Ticket Picked Up By: ___________________________________________

Expected Date for Follow-Up / Repairs: ____________________________

Completion Date for Follow-Up / Repairs: __________________________

Notes: _______________________________________________________________________________________

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Repair Journal System

OCCUPANT MANAGEMENT

Repair Needed Occupant Name, Date Reported

Housing Location

Manager Name, Date Checked, Note

Date Repair Expected

Date Repair Completed

Stove burner not working

Juan 5/4/2018 House #3

Greg, 5/5/2018, burner just loose,cleaned and fixed.

5/5/2018 5/5/2018

Adapted from Cornell Agricultural Workforce Development.

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Cleaning ScheduleThis suggested cleaning schedule can help farm housing occupants plan.

DAILY TASKS WEEKLY TASKS OCCASIONAL CHORES SEASONAL CHORES

KitchenWash dishes Wipe countertops Wipe out sink Empty garbage Sweep floor

Dispose of leftover food Mop floorClean garbage pailWipe out microwave

Clean drip pans on range Clean ovenDefrost and clean refrigerator Wash walls and woodwork

Clean cupboardsScrub floors

Bathroom

Wipe our sink and tubReplace soiled towels Empty waste baskets

Wash floor Launder towels Clean toilet bowl Wipe tile surfacesClean mirrorsClean sink, shower and tub

Wash bath matWipe walls and woodwork

Clean closets

Living RoomClean ash traysDispose of papersStraighten magazines, DVDs, CDs and throw pillows

Vacuum rugs and furniture Vacuum or dust floorsDust furniture, lamps and accessories

Shampoo rugs and furniture Wipe lamp shadesMove and clean under furnitureWash windows and curtains Dust books and pictures

Clean closetsClean screens or storm windowsWax floorsWipe walls and woodworkScrub floors

Bedrooms

Put away clothes Launder bed linensVacuum and dust

Turn mattressesWash mattress covers and padWash pillowsWipe walls and woodwork

Wash or dry clean blankets and spreadOrganize closets

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Adapted from Kansas State University Cooperative Extension.

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